Requirements of Medicare Opt-Out Affidavit Agreement

Amendment 4507 of the Balanced Budget Act of 1997 permits a physician or practitioner to “opt out” of Medicare and enter into private contracts with Medicare beneficiaries if specific requirements are met.

Under the statute, the physician or practitioner cannot choose to opt out of Medicare for some Medicare beneficiaries, but not others. If the decision is made to opt out, then private contracts will need to be provided for all Medicare beneficiaries the physician or practitioner renders services.

Once you enter into a private contract agreement with a beneficiary, please complete and submit the NGS Medicare Opt Out Affidavit form. This will ensure you are meeting all the requirements of opt-out regulations.

Related Content

• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 40
• CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 10.6.1.12
• Medicare Part B 101 Manual - Provider Enrollment – Private Contracting and Opt Out

Revised 11/12/2021